HIV Risky Sexual Behaviors and HIV Infection Among Immigrants: A Cross-Sectional Study in Lisbon, Portugal.

Int. J. Environ. Res. Public Health 2014, 11, 8552-8566; doi:10.3390/ijerphl 10808552

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Article

HIV Risky Sexual Behaviors and HIV Infection Among
Immigrants: A Cross-Sectional Study in Lisbon, Portugal

Sonia Dias '*, Adilson Marques 2 , Ana Gama 1 and Maria O. Martins 1

1 Instituto de Higiene e Medicina Tropical - Centro de Malaria e Outras Doencas Tropicais,
Universidade Nova de Lisboa, Rua da Junqueira n° 100, Lisboa 1349-008, Portugal;
E-Mails: anafgama@gmail.com (A.G.); mrfom@ihmt.unl.pt (M.O.M.)

2 Faculdade de Motricidade Humana, Universidade de Lisboa, Estrada da Costa,
Cruz Quebrada-Dafundo 1499-002, Portugal; E-Mail: amarques@fmh.ulisboa.pt

* Author to whom correspondence should be addressed; E-Mail: smfdias@yahoo.com;
sfdias@ihmt.unl.pt; Tel.: +351-213-652-600; Fax: +351-213-632-105.

Received: 1 July 2014; in revised form: 23 July 2014 / Accepted: 12 August 2014 /
Published: 20 August 2014

Abstract: This study aimed to examine risky sexual behavior, its associated factors and
HIV infection among immigrants. A participatory cross-sectional survey was conducted with
1187 immigrants at the National Immigrant Support Centre, in Lisbon (52.2% female;
34.0% Africans, 33.8% Brazilians, 32.2% Eastern Europeans). About 38% of participants
reported >2 sexual partners in the previous year, 16.2% both regular and occasional sexual
partners (last 12 months), 33.1% inconsistent condom use with occasional partners, and
64% no condom use in the last sexual intercourse. Unprotected sex in the last sexual
intercourse was more likely among women, Africans, those older, with elementary
education, those married and those who didn't receive free condoms in the previous year.
No condom use was less likely among those having only occasional sexual partners and
both regular and occasional sexual partners. One third of participants had never been tested
for HIV. Those never tested reported more frequently inconsistent condom use than those
ever tested. Overall, 2.0% reported being HIV positive (2.5% of men; 4.4% of Africans);
4.3% admitted having a STI in previous year. HIV-positive immigrants reported high-risk
sexual behaviors. Tailored interventions to promote awareness of HIV serostatus among
immigrants as well as culturally adapted risk reduction strategies should be strengthened.

Int. J. Environ. Res. Public Health 2014, 11

Keywords: immigrants; HIV infection; risky sexual behavior

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1. Introduction

The HIV epidemic continues to be a major public health concern in the European Union [1,2].
Increased international migration, particularly from highly endemic countries, has been acknowledged
as one of the major factors influencing the epidemiology of HIV in Europe and contributing to the
changing pattern of HIV transmission in this region, where in the recent years sexually transmitted
cases have been on the rise [3]. Estimates indicate that approximately 40% of the HIV diagnosed cases
during 2007-201 1 in Europe were in migrants [1].

Migration had been recognized to be associated with increased high risk sexual behaviors [4,5].
Previous research indicate that a considerable amount of immigrants report to have multiple partners
and to not use condom consistently with both occasional (casual partner with no committed
relationship) and regular (main, stable partner) partners [6-9], which renders this population
particularly at risk for HIV infection. Explanations of the increased vulnerability of immigrants to HIV
infection include the long periods away from family and partners, the associated need to seek
companionship to compensate for the alienating aspects of the migration experience and the fewer
social controls on behavior [9,10], but also the experience of social exclusion and lack of legal
protection that often translate in lesser means of protection and poorer health status [7,9], and barriers
to health services (related to their legal status, socioeconomic conditions, language and cultural
difference) [3,11-13].

Despite the evidence of disproportionate HIV risk among migrants and increasing numbers of
immigrants in the European context, there are few studies aimed to examine the extent of HIV
infection, risky sexual behavior and its determinants among these populations. Additionally, many
immigrants have not even been systematically included in HIV surveillance systems, as undocumented
and recent immigrants who are omitted in the population census and records. Also, many groups
underuse health services where surveillance data is reported (mainly due to mistrust or lack of
knowledge about services available and migrants' health rights). Furthermore, in many cases data are
not collected in a way that allows disaggregated analysis (in many countries no data is collected on
variables as country of birth or ethnic group) [14,15].

Knowledge on HIV infection and risk behavior among immigrants is greatly needed to inform HIV
prevention and control national programs as well as to provide valuable evidence for appropriate
interventions in this population. This is particularly relevant in Portugal as it is one of the countries
presenting the largest burden of infection in Western Europe-data estimates that in 2011 it had one of
the highest incidence rates (11.8 per 100,000 population; 17.2 per 100,000 males and 6.7 per 100,000
females) and the second highest HIV prevalence (0.7% among adults aged 15-49 years old) in the
European Region [16,17]. Also, in the last decades Portugal has received many immigrants (the
foreign-born population represent 8.3% of the total population in Portugal), mainly from countries with
high HIV prevalence as most Portuguese-speaking African countries, Eastern European countries and
Brazil [17-19]. In 2012, 29.4% (228) of the newly diagnosed cases in Portugal referred to immigrants:

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66.4% from Sub-Saharan Africa, 20.0% from Latin America, 11.4% from Europe [20]. This study
aimed to examine risky sexual behaviors, its associated factors and HIV infection among immigrants
in the Lisbon Metropolitan Area.

2. Methods

2.1. Study Design and Population

A cross-sectional survey was conducted with immigrants in the Lisbon Metropolitan Area.
This area has currently the highest concentration of immigrant population in the country. Official data
indicate that, in 2011, 44% of the immigrant population in Portugal resided in the Lisbon region
(around 188,259 and an undetermined number of undocumented persons excluded in the official
statistics) [21]. A participatory approach was used: representatives of governmental organizations
(public health services), non-governmental organizations (NGOs) and associations of African,
Brazilian and Eastern European immigrants (who work in outreach projects in the areas of health
promotion, HIV prevention and social support with immigrant communities) actively collaborated in
all phases of the study.

2.2. Sampling and Data Collection

The study sample included 1187 immigrants who were interviewed at the National Immigrant
Support Centre (NISC) in Lisbon over a 1 month period (February) in 2011. The NISC is part of the
High Commission for Immigration and Intercultural Dialogue. Within a friendly environment,
it provides integrated answers to needs faced by immigrants residing in Portugal (e.g., regularization
process, interaction with public services) regardless of legal status or any other criterion. It brings
together in one place different public institutions in the areas of health, education, social security,
employment and justice [22,23].

All immigrants who visited the NISC premises during working hours were approached and invited
to participate. The inclusion criteria were being an immigrant, defined as a non-national person who
migrated to Portugal for the purpose of settlement [24], and being >18 years old. The proportion of
refusals was 9.7% (n = 127; 57.7% were female). No further information was collected from those
who refused.

Data were collected through an anonymous structured questionnaire. Given the sensitive nature of
the subject under investigation, the interviews took place in a quiet and isolated room at NISC offices
to ensure privacy and comfort of participants. The questionnaire was applied by trained interviewers
from immigrant communities, recruited and selected in collaboration with NGOs and immigrant
associations. Interviews were applied in Portuguese — it is the official language of Africans and
Brazilians in Portugal and many Eastern Europeans are fluent in Portuguese. In the few cases of
Eastern Europeans who weren't fluent in Portuguese, specific interviewers applied the questionnaire in
the native language. The questionnaire was administered using pen and paper. The interviewers
training included information about the questionnaire, the data collection procedures and general
interview techniques.

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Anonymous participation and confidentiality of data was guaranteed. Informed consent was
obtained. The study was approved by the Ethical Committee of Instituto de Higiene e Medicina
Tropical, Universidade Nova de Lisboa.

2.3. Instrument

The questionnaire comprised items on socio demo graphic characteristics, sexual behaviors,
HIV testing, self-reported HIV infection and other STI, use of health services and prevention
initiatives. In more detail:

Sociodemographic characteristics: These included sex, age (continuous variable), educational level
("elementary", "secondary", "higher"), marital status ("single", "married", "divorced or separated" and
"widowed"; for analysis these options were dichotomized into "unmarried" — single/divorced or
separated/widowed — and "married"), professional situation ("employed part-time", "employed full-time",
"working-student", "student", "unemployed" and "retired"; for analysis these options were dichotomized
into "non-employed" — student/unemployed/retired-and "employed"-employed part-time/employed
full-time/working-student), perceived monthly income ("very insufficient", "insufficient", "sufficient"
and "more than sufficient"; for analysis these options were dichotomized into "insufficient" and
"sufficient"), and migration-related characteristics such as origin (response options included a list of
countries which were then aggregated into "African", "Brazilian" and "Eastern European"), length of
stay (in months for those residing in Portugal for <1 year, and in years for those residing for >1 year)
and immigration status ("undocumented", "documented").

Sexual behaviors: Participants were asked about age at first sexual intercourse (in years);
engagement in sexual intercourse (yes/no), number and type of sexual partners, commercial sex
(yes/no), sex with a same-sex partner (yes/no) and condom use by type of sexual partner in the
reference period of 12 months; type of sexual partner and condom use in the last sexual intercourse.
Regarding type of sexual partner, two response options were used (regular/occasional partner) —
regular sexual partner was defined as a person with whom one has sexual intercourse and has plans for
further long term or committed relationship; occasional sexual partner was defined as a person with
whom one has sexual intercourse (without payment) and has no plans for further long term or
committed relationship [8]. As these response options were not mutually exclusive, for the analysis they
were categorized into "only regular", "only occasional" and "regular and occasional". Engagement in
commercial sex was defined as having had sexual intercourse with a person involving money or goods
exchange between the two parties [25]. Regarding condom use in the last 12 months, participants were
asked how often a condom was used (by him/herself or his/her sexual partner) during their sexual
relations, having three possible response options (always/sometimes/rarely or never). For analysis this
variable was dichotomized into consistent (always) and inconsistent (sometimes/rarely or never) condom
use. Participants were also asked whether a condom was used (by him/herself or his/her sexual partner)
in their last sexual intercourse, being the possible response options "yes" and "no".

HIV testing: Participants provided information on whether they had been tested for HIV ever and in
the previous 12 months, both questions with "yes'V'no" response options.

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HIV/STI status: Participants were asked to self-report their current serostatus for HIV and their
serostatus for other sexually transmitted infections (STIs) in the last 12 months.

Use of health services and prevention initiatives: Participants were asked about ever use of health
services in Portugal, ever attendance of a sexual and reproductive health consultation and having
received free condoms in the previous 12 months, all with "yes'V'no" response options.

The questionnaire was designed in order to provide data for the second generation indicators created
in accordance with international guidelines [26,27]. The items used in the questionnaire were also
based on other international HIV research projects on migrants [28-30]. The instrument was
constructed along with feedback provided by the partners of the study. The questionnaire was
pre-tested with members of immigrant communities; few amendments were made to improve clarity
and appropriateness of the questions to the study populations.

2.4. Data Analysis

Data analysis was performed using IBM SPSS Statistics v.22. The bivariate associations between
sociodemographic characteristics, migration-related variables, sexual behaviors, HIV testing, self-reported
infection, use of health services, prevention initiatives and gender were assessed using x, 2 and Fisher's
exact tests when appropriate. Logistic regression analyses were performed to estimate the crude odds
ratios (OR), adjusted OR and 95% confidence intervals (CI) of factors associated with no condom use
in the last sexual intercourse. For analysis of sexual behaviors in the previous 12 months, 176 participants
were excluded as they haven't reported sexual intercourse during this period.

3. Results

3.1. Characteristics of Participants

The socio-demographic and migration-related characteristics of the male and female participants are
shown in Table 1. In brief, 52.2% of the sample was female. Approximately two thirds of the
participants were 25-44 years old. Overall, 34% were Africans (from Portuguese-speaking African
countries: Angola, Cape Verde, Guinea Bissau, Mozambique, and Sao Tome and Principe), 33.8%
were Brazilians and 32.2% Eastern Europeans (from Ukraine, Moldavia, Russia, Romania, Belarus and
Bulgaria). About 38% had secondary education, more men than women (p = 0.028). More than a half
of participants were not married. A third reported being undocumented, 47.1% were non-employed
and 57.6% perceived their monthly income as insufficient. Mean length of stay in Portugal was
7.5 years (±7.5).

Table 1. Socio-demographic and migration-related characteristics by gender.

Total Men Women p "

n % n % n %

1187 100 567 47.8 620 52.2

0.173

189 15.9 101 17.8 88 14.2

751 63.3 356 62.8 395 63.7

247 20.8 110 19.4 137 22.1

Total

Age (years) (n = 1 187)
18-24
25-44
45-65

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Table 1. Cont.

Total Men Women p"

n

%

n

%

n

%

Origin (n= 1187)

0.997

Eastern European

383

32.2

183

32.3

200

32.2

Brazilian

401

33.8

191

33.7

210

33.9

African

403

34.0

193

34.0

210

33.9

Educational level (n = 1 1 82)

0.028

Higher

419

35.4

187

33.2

232

37.5

Secondary

448

37.9

236

41.8

212

34.3

Elementary

315

26.6

141

25.0

174

28.2

Marital status (« = 1184)

0.457

Unmarried

723

61.1

340

60.0

383

62.1

Married

461

38.9

227

40.0

234

37.9

Immigration status (n = 1 176)

0.084

Undocumented

390

33.2

200

35.7

190

30.9

Documented

786

66.8

361

64.3

425

69.1

Professional status (n = 1 1 87)

0.905

Non-employed

559

47.1

266

46.9

293

47.3

Employed

628

52.9

301

53.1

327

52.7

Perceived monthly income [n = 1 1 84)

0.904

Insufficient

682

57.6

325

57.4

357

57.8

Sufficient

502

42.4

241

42.6

261

42.2

Mean ± SD

Mean ± SD

Mean ± SD

P h

Length of stay in Portugal (years) (n = 1181)

7.5 ±7.5

7.8

±7.9

7.2 ±7.1

0.200

Tested by Chi-square or Exact Fisher Test; b Tested by T-test.

3.2. Risk Sexual Behaviors, HIV Testing and HIV Infection

Table 2 presents the data on risk sexual behaviors, HIV testing and reported HIV infection of the
participants stratified by gender. Compared to women, men reported lower mean age at first sexual
intercourse and higher number of sexual partners in the last year. Also, a higher proportion of men
reported having both regular and occasional sexual partners in the last year and having their most
recent sexual intercourse with an occasional partner. Also, a higher proportion of men reported
engagement in sexual intercourse with same-sex partners and in commercial sex in the previous year,
comparing to women.

Condom use with occasional partners in the last 12 months was inconsistent among 33.1% of
participants, significantly more women than men (44.8% and 28.7%, respectively). Inconsistent
condom use with regular partners was reported by 81.7% of participants, with no significant
differences across gender. About 73% of women and 54.2% of men didn't use condom at their most
recent sexual intercourse.

Approximately 38% of participants reported having never been tested for HIV, more men than
women; of those ever tested, 63.4% were not tested in the last year. Those never tested reported more
frequently inconsistent condom use with occasional partners (42.7% compared to 28.9% of those ever
tested for HIV, p = 0.034) and with regular partners (85.2% vs. 79.8% of those ever tested for HIV,
/? = 0.05).

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Table 2. Risk sexual behaviors, HIV testing, reported HIV infection, use of health services
and prevention initiatives by gender.

Total Men Women

Mean ± SD

Mean ± SD

Mean ± SD

P*

Age at first sexual intercourse (n = 975)

16.9 ±2.9

16.2 ±2.9

17.5 ±2.8

<0.001

n

%

n

%

n

%

h

p

Number of sexual partners in the previous

<0.001

12 months (n = 974)

1 partner

604

62.0

233

50.0

371

73.0

2-3 partners

256

26.3

147

31.5

109

21.5

> 4 partners

114

11.7

86

18.5

28

5.5

Type of sexual partners in the previous

<0.001

12 months (n = 998)

Only regular

737

73.8

284

59.9

453

86.5

Only occasional

99

9.9

77

16.2

22

4.2

Regular and occasional

162

16.2

113

23.8

49

9.4

Sexual intercourse with same-sex partners in

0.007

the previous 12 months (n = 1002)

No

943

94.1

437

92.0

506

96.0

Yes

59

5.9

38

8.0

21

4.0

Commercial sex in the previous 12 months (n = 1011)

0.002

No

972

96.1

450

94.1

522

97.9

Yes

39

3.9

28

5.9

11

2.1

Type of sexual partner at the most recent sexual

<0.001

intercourse (n = 1008)

Regular

827

82.0

348

73.0

479

90.2

Occasional

181

18.0

129

27.0

52

9.8

Condom use with regular partners in the

0.068

previous 12 months (n = 890)

Consistent

163

18.3

83

21.0

80

16.2

Inconsistent

727

81.7

313

79.0

414

83.8

Condom use with occasional partners in the previous

0.017

12 months (n = 248)

Consistent

166

66.9

129

71.3

37

55.2

Inconsistent

82

33.1

52

28.7

40

44.8

Condom use in the last sexual encounter (n = 992)

<0.001

No

635

64.0

254

54.2

381

72.8

Yes

357

36.0

215

45.8

142

27.2

Ever testing for HIV (n = 1 185)

O.001

Yes

740

62.4

316

55.8

424

68.5

No

445

37.6

250

44.2

195

31.5

Reported HIV status (n = 735) 1

0.407

Negative

720

97.3

307

97.5

413

98.3

Positive

15

2.0

8

2.5

7

1.7

Ever utilization of health services in Portugal (n = 1 186)

<0.001

No

207

17.5

125

22.0

82

13.2

Yes

979

82.5

442

78.0

537

86.8

Attendance to a sexual and reproductive

<0.001

consultation (n = 1 169)

No

876

74.9

489

87.6

387

63.3

Yes

293

25.1

69

12.4

224

36.7

Free condoms received in the previous

0.047

12 months (n =1186)

Yes

391

33.0

203

35.8

188

30.4

No

795

67.0

364

64.2

431

69.6

1 For the analyses it was only considered participants who reported to have been tested for HIV; a Tested by T-test;
b Tested by Chi -square or Exact Fisher Test.

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Of those ever tested for HIV, 15 participants (2.0%) reported being HIV positive: 2.5% of men and
1.7% of women; 4.4% (n = 12) of Africans, 1.2% {n = 2) of Eastern Europeans and 0.3% {n = 1) of
Brazilians (data not shown in the table). HIV-positive participants reported high-risk sexual behaviors:
nine participants (60.0%) had two or more sexual partners in the last year, six (40.0%) had occasional
sexual partners and three (20.0%) both regular and occasional sexual partners in the last year, four
(26.7%) inconsistently used condom with occasional partners and four (26.7%) with regular partners.
No significant differences were found across gender and origin.

Overall, 4.3% (n = 50) of participants admitted having a STI in the previous year: 5.1% (n = 31) of
women and 3.5% (n = 19) of men; 6.1% (n = 24) of Africans, 4.0% (n = 16) of Brazilians and 2.8%
(n = 10) of Eastern Europeans.

3. 3. Use of Health Services and Preventive Initiatives

Table 2 also shows the distribution of ever use of health services, attendance to a sexual and
reproductive health consultation and free condoms received by gender. A significantly higher
proportion of women reported having ever used the health services and having attended a sexual and
reproductive health consultation, while men reported more frequently having received free condoms in
the previous year. Participants who ever used health services reported more frequently having been
tested for HIV compared to those who never used (64.5% vs. 52.7%, p = 0.001). Similar result was
found for attending a sexual and reproductive health consultation (74.7% among those who had
attended vs. 58.6% of those who never attended, p < 0.001) (data not shown).

3. 4. Factors Associated with no Condom Use in the Last Sexual Intercourse

Logistic regression estimation results for factors associated with the likelihood of not having used
condom in the last sexual intercourse are presented in Table 3. After adjusting the logistic regression
model to all variables presented in the analysis, having not used condom was more likely among
women (OR = 1.73, 95% CI: 1.25-2.40), Africans (OR = 1.81, 95% CI: 1.11-2.96) compared to
Eastern Europeans, those older (OR = 1.84, 95% CI: 1.02-3.32), those with elementary education
(OR = 1.84, 95% CI: 1.11-3.01) compared to higher education, those married (OR = 2.38, 95% CI:
1.67-3.38) and those who didn't receive free condoms in the previous year (OR = 1.49, 95%
CI: 1.06-2.09). No condom use was less likely among immigrants who had only occasional sexual
partners (OR = 0.10, 95% CI: 0.05-0.20) and both regular and occasional sexual partners (OR = 0.43,
95% CI: 0.25-0.75).

Table 3. Logistic regression results for factors associated with no condom use in the last
sexual intercourse.

«(%)(« = 635) Crude OR (95% CI) Adjusted OR (95% CI)

Sex

Male

Female
Origin

Eastern European

254 (54.2)
381 (72.8)

184 (64.3)

1.00

2.27 (1.74-2.96) ***

1.00

1.00

1.73 (1.25-2.40) **

1.00

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Table 3. Cont.

n (%) (« = 635)

Crude OR (95% CI)

Adjusted OR (95% CI) 1

Brazilian

215 (57.5)

0.75 (0.55-1.03)

1.05 (0.68-1.61)

African

236 (71.1)

1.36 (0.97-1.91)

1.81 (1.11-2.96)*

Age (years)

18-24

78 (50.0)

1.00

1.00

25-44

418 (63.5)

1.74(1.23-2.48) **

1.20 (0.77-1.87)

45-65

139 (78.1)

3.56 (2.22-5.73) ***

1.84(1.02-3.32)*

Educational level

Higher

206 (61.9)

1.00

1.00

Secondary

235 (59.0)

0.89 (0.66-1.20)

1.40 (0.95-2.07)

Elementary

191 (74.3)

1.78 (1.25-2.55) **

1.84(1.11-3.01) *

Marital status

Unmarried

301 (52.8)

1.00

1.00

Married

332 (79.0)

3.37 (2.53-4.49) ***

2.38 (1.67-3.38) ***

Number of sexual partners

1 partner

447 (75.4)

1.00

1.00

2-3 partners

138 (54.3)

0.39 (0.29-0.53) ***

0.94 (0.60-1.48)

>4 partners

31 (27.7)

0.13 (0.08-0.20) ***

0.76 (0.38-1.50)

Type of sexual partners in the

previous 12 months

Only regular

546 (75.6)

1.00

1.00

Only occasional

14(14.1)

0.05 (0.03-0.10) ***

0.10 (0.05-0.20) ***

Regular and occasional

71 (44.7)

0.26 (0.18-0.37) ***

0.43 (0.25-0.75) **

Free condoms received in the

previous 12 months

Yes

184 (51.8)

1.00

1.00

No

451 (70.8)

2.25 (1.72-2.95) ***

1.49(1.06-2.09) **

Ever testing for HIV

Yes

410 (62.6)

1.00

1.00

No

225 (66.8)

1.20 (0.91-1.58)

1.13 (0.80-1.59)

1 Adjusted for sex, origin, age, educational level, marital status, number of sexual partners, type of sexual partners in the
previous 12 months, free condoms received in the previous 12 months and ever testing for HIV. * p < 0.05; ** p < 0.01;
"'p< 0.001.

4. Discussion

In general, the results of this study indicate high rates of risky sexual behaviors among immigrants,
including having multiple (concurrent) sexual partners and unprotected sexual intercourse, consistently
with other research conducted in Europe [6,31] and in other regions [9,29,32,33]. These findings
highlight the potential increasing risk for HIV infection of migrants who have unprotected sex with
multiple sexual partners, but also if they acquire HIV/AIDS the increasing likelihood of transmitting
HIV infection to their partners.

As would be expected, we found wide variability in sexual risk behaviors across gender. Women
reported significantly less condom use than men. This can be strongly related to gender power
inequalities and lack of negotiating capacity to request safer sex, which renders women particularly
vulnerable to partners' risk behaviors [34,35]. On the other hand, although consistent condom use was
more frequent among men, the reported higher rates of multiple sexual partners, engagement in

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commercial sex and with same-sex partners puts this subgroup at increased risk for HIV infection.
A key element to be explored in future research is the variations in the pattern of risk practices through
the different phases of the migration process and within each geographic context.

The overall reported HIV prevalence in this study was 2% and 4.4% in the African subgroup, much
higher compared to that estimated for the general national population (0.7% among individuals aged
15-49 years) [17]. The scant published research in the European context show relatively great levels of
infection. In a cross-sectional survey conducted in London with a convenience sample of Central and
Eastern European migrants, 1.1% of respondents reported being HIV positive [6]. A study carried out
in HIV counselling and testing clinics in several Spanish cities included a sample of immigrants who
voluntarily tested for HIV and the HIV prevalence obtained ranged from 1.7% in Central and Eastern
Europeans and in Latin Americans, 2.4% in North Africans and 8.4% in Sub-Saharan Africans [36].
In other cross-sectional community-based survey conducted with 1006 black- Africans in England,
14% of participants tested HIV positive [30]. Given that our data is solely based on self-reported
information with absence of biological samples, we can speculate that the proportion of HIV-positive
immigrants among our sample is probably higher.

The greater prevalence of HIV among African immigrants found in our sample has also been
described in other European studies [30,36-38]. This certainly can be related to the higher prevalence
of HIV in their countries of origin but also to their greater exposure to HIV risk. Indeed, African
immigrants reported higher rates of risk sexual behaviors (multiple sexual partners, concomitant
partners in the last year and inconsistent condom use-from further analysis not shown). In future
research it is essential to further explore the patterns of risk behaviors of migrants and the underlying
individual, sociocultural and contextual factors as also the epidemiological background.

A relevant result in our study is the observation of risky sexual behaviors among HIV-positive
immigrants. Although caution is needed when analyzing the results because the sample size is small, a
relatively large proportion of these participants reported having multiple sexual partners, having both
regular and occasional partners in the previous year and engaging in unprotected sex, which poses
direct risks for HIV transmission. Secondary prevention strategies are warranted to foster safer sex
practices among those living with HIV.

It is also important to point out the high reported prevalence of STI found in this study. There is
clear evidence that STI increase the likelihood of HIV transmission and similar sexual behaviors place
people at high risk of both infections [39]. Our findings reinforce the need of strengthening integrated
HIV and STI prevention and control programs among immigrants.

Approximately 38% of immigrants in this study reported having never been tested for HIV and of
those who ever tested, 63.4% were not tested in the last year. These may include a potential group of
immigrants with undiagnosed HIV infection. Moreover, immigrants who never tested for HIV reported
more frequently risky sexual behavior. Evidence gained in continued experience in HIV testing
indicates that increasing individuals' awareness of HIV infection and counseling them to develop
appropriate sexual protective measures leads to substantial reductions in high-risk sexual
behavior [40-42]. Therefore, promotion of HIV testing among this population should be sustained.

When promoting HIV testing it must be taken into account the important finding observed in this
study and in other research that having never been tested for HIV is significantly associated with
having never used health services or attended a sexual reproductive health consultation [43,44].

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Our results show a considerable proportion of immigrants who never used the health services, in line
with previous studies [45-48]. Although no specific data were collected on barriers in utilization of
health services, the literature points out migrants' lack of knowledge on the health services available,
the lack of cultural competence of health professionals and structural barriers as cost, distance of
health services and legal restrictions [12,46,49,50]. These findings support the need to overcome
barriers and promote the use of health services in order to reduce missed opportunities for early
detection of HIV and prevention among this population.

Immigrants who received free condoms were less likely to had unprotected sex, suggesting that the
provision of free condoms to other immigrants can have the same benefits. Additionally, we found a
relationship between low educational level and having not used condom in the last sexual intercourse.
A possible explanation is that lower educational level, frequently related to the lack of knowledge on
HIV transmission and prevention, may hinder risk perception and increase the adoption of unsafe
sexual practices [8,25,51,52]. Community-based initiatives promoted by outreach teams who have
trusting relationships with the community and have unique knowledge of its context can contribute to
promote effective HIV prevention interventions among these populations [10,53].

The findings must be interpreted with consideration of some limitations. The cross-sectional nature
of the data limits our ability to draw causal inferences. Another limitation relates to the sampling
procedure. Although the study achieved a diverse and large sample we did not use a random sampling
method to select the study population. In fact, the information available on immigrant population in
Portugal does not allow constructing sampling frames for representative population-based surveys that
capture hard-to-reach subgroups as undocumented and recent immigrants. Collecting data only from
migrants presenting themselves at the NISC potentially leads to an overrepresentation of more affluent
and better integrated migrant groups. However, as this center is viewed by immigrants as an
independent institution dedicated to solving individual integration problems, we are confident that the
sampling procedure allowed for a fairly representative sample of migrant conditions. Also, the participants'
socio-demographic profiles are in line with data on immigrant populations in Portugal [19]. We did not
collect data on reasons for refusals, but the topic explored in this study may have motivated individuals
to refuse, which could mask a higher prevalence of risk behaviors and infection among this population.
As in many other investigations, another limitation is the collected information based on self-reports.
Due to the intimate and sensitive nature of the study subject and the high degree of stigma and
discrimination attached to risky sexual behavior and HIV/STI positive serostatus, response bias toward
under-reporting in this study would be expected.

Despite study limitations, this large-scale study provides useful insights on risky sexual behavior
and HIV infection/STI among immigrants. In order to improve our understanding of the complex
dynamics of HIV risk and infection in this population further research is needed.

5. Conclusions

In summary, this study shows that a considerable proportion of immigrants engage in risky sexual
behaviors rendering them at high risk for HIV infection. Our findings highlight that efforts to promote
HIV testing and awareness of HIV serostatus among immigrants as well as culturally adapted
interventions promoting risk reduction strategies should be strengthened. Given the enormous

Int. J. Environ. Res. Public Health 2014, 11

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heterogeneity of immigrant communities, tailored interventions should be developed targeting subgroups
prone to high risk sexual behaviors and matching their specific prevention needs.

Acknowledgments

This work was partially supported by National Coordination for HIV/AIDS Infection. We wish to
thank all participants of this study. We are very grateful to all the community partners of the project.
We also would like to acknowledge the commitment of the team of interviewers who were responsible
for the collection of the study data.

Author Contributions

Sonia Dias and Ana Gama designed the study and coordinated the data collection process. Adilson
Marques and Maria O. Martins were responsible for all statistical analyses. All authors wrote,
reviewed the manuscript and approved the final version.

Conflicts of Interest

The authors declare no conflict of interest.
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